http://informahealthcare.com/bijISSN: 0269-9052 (print), 1362-301X (electronic)

Brain Inj, Early Online: 1–10! 2014 Informa UK Ltd. DOI: 10.3109/02699052.2014.947619

ORIGINAL ARTICLE

Assessment practices of speech-language pathologists for cognitivecommunication disorders following traumatic brain injury in adults:An international survey

Matthew Frith1,2,3, Leanne Togher2,3, Alison Ferguson4, Wayne Levick5, & Kimberley Docking2,3

1Kaleidoscope: Children, Young People & Families, Hunter New England Local Health District, NSW, Australia, 2Speech Pathology, Faculty of Health

Sciences, University of Sydney, Sydney, Australia, 3NHMRC Centre of Research Excellence in Brain Recovery, Sydney, Australia, 4School of Humanities

& Social Sciences, and 5School of Psychology University of Newcastle, Newcastle, Australia

Abstract

Primary objective: This study’s objective was to examine the current assessment practices ofSLPs working with adults with acquired cognitive communication impairments following a TBI.Methods and procedures: Two hundred and sixty-five SLPs from the UK, the US, Canada,Australia and New Zealand responded to the online survey stating the areas of communicationfrequently assessed and the assessment tools they use.Main outcomes and results: SLPs reported that they routinely assessed functional communi-cation (78.8%), whereas domains such as discourse were routinely assessed by less than half ofthe group (44.3%). Clinicians used aphasia and cognitive communication/high level languagetools and tools assessing functional performance, discourse, pragmatic skills or informalassessments were used by less than 10% of the group. The country and setting of servicedelivery influenced choice of assessment tools used in clinical practice.Conclusions: These findings have implications for training of SLPs in a more diverse range ofassessment tools for this clinical group. The findings raise questions regarding the statisticalvalidity and reliability of assessments currently used in clinical practice. It highlights the needfor further research into how SLPs can be supported in translating current evidence about theuse of assessment tools into clinical practice.

Keywords

Assessment, cognitive, language, survey

History

Received 25 August 2013Revised 16 May 2014Accepted 20 July 2014Published online 26 August 2014

Introduction

Speech Language Pathologists (SLPs) play an integral role in

the rehabilitation of a person after a traumatic brain injury

(TBI). SLP assessment and intervention commences in the

acute setting with a focus primarily on dysphagia manage-

ment [1], observation and monitoring of communication

abilities during post-traumatic amnesia [2] and further on

in the rehabilitation process SLPs have an important contri-

bution in cognitive rehabilitation, with assessment and

management of cognitive communication disorders [3].

Rehabilitation after a TBI is a specialized field and requires

expert clinical decision-making skills where there is an

understanding of the person’s impairments in communication

and how this relates to their ability to participate in real life

activities [4].

Considering this is a complex specialized field, there is

limited consensus in the literature to assist the SLP to

make appropriate clinical decisions regarding the type of

methodology and complimentary assessment choices in this

rehabilitation setting. One approach is to use locally regulated

SLP practice guidelines, but internationally there are incon-

sistencies amongst speech language pathology associations

on practice guidelines for the assessment and management

of cognitive communication disorders. In countries such as

Australia and New Zealand there are no practice guidelines or

position papers regarding the selection of relevant assess-

ments in this specialized field of practice and in the UK,

while the Royal College of Speech & Language Therapists

(RCSLT) have produced guidelines [5] for the assessment and

management of aphasia, as yet there is no reference to

cognitive communication disorders. However, more detailed

guidelines are available through the US and Canada. The

American Speech-Language-Hearing Association [6, 7] have

produced a number of general guidelines and position papers

on the assessment of cognitive communication disorders,

while The College of Audiologists and Speech Language

Pathologists of Ontario [8] have produced detailed preferred

practice guidelines for both the assessment and management

of cognitive communication disorders. Both papers make

reference to assessment of cognitive functions such as

attention, concentration, executive function, memory/new

learning as well as linguistic components such as auditory

Correspondence: Matthew Frith, Speech Pathologist, Kaleidoscope,HNE LHD PO BOX 2563 Dangar, NSW, Australia 2309, Australia.Tel: +61(0)249 257963. Fax: +61(0)249257955. E-mail:matthew.frith@hnehealth.nsw.gov.au

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comprehension, oral expression, discourse, word finding,

reading rate and comprehension and written expression.

The Academy of Neurologic Communication Disorders

and Sciences (ANCDS) has similarly published guidelines on

standardized testing [9] and non-standardized testing [10].

Surprisingly, these guidelines have received very little

citation, but they do provide valuable information for the

SLP to guide clinical decision-making. The ANCDS surveyed

clinicians and test distributors about assessments that are

recommended to be used in TBI and cognitive communica-

tion disorders [9]. These were reviewed by the ANCDS

committee for reliability and validity and of 85 tests, only six

were recommended for adult patients that met the majority of

criteria for reliability and validity. The tests which were

recommended by the ANCDS committee included

the Functional Independence Measure FIM [11]; American

Speech Language Hearing Association Functional

Assessment of Communication Skills in Adults ASHA

FACS [12]; Communication Activities of Daily Living

Second Edition CADL-2 [13]; Repeatable Battery for the

Assessment of Neuropsychological Status RBANS [14]; and

the Western Aphasia Battery WAB [15]. Some of the

described [10] non-standardized assessment procedures used

by Speech Language Pathologists focused mainly on dis-

course procedures including monologic and conversational

discourse. The authors discussed some of the inherent

weaknesses with non-standardized approaches, such as lack

of normative data to distinguish impaired and normal

discourse abilities within the context of the person and the

influences context has on discourse. It was also recommended

that rating scales and checklists used in discourse and

pragmatic assessments about the person and communication

partner should be used with caution due to weak psychometric

properties and the level of training required to reliably use

them.

Not much has been documented on the influence of

assessment choices for SLPs working with people with TBI.

Surveys of SLPs working in TBI in the US have highlighted

that undergraduate training does not provide adequate training

in TBI [16, 17]. The questions that a clinician should ask

themselves when deciding on an assessment have been

described in detail [18]. These four questions consisted of:

(1) Does the test identify a cognitive communication

disorder?; (2) Does it characterize the components contribut-

ing to the performance?; (3) Are the test results appropriate

for the real life situations?; and (4) Does it assist with

decisions about intervention? The statistical aspects of test

construction and its importance in test selection has been

discussed [9], however a survey conducted in the US

suggested that, despite poor validity and reliability, the

choice of assessment by SLPs was most commonly based

on whether it identified deficits and assisted with goal-setting

and therapeutic planning [19]. The same survey demonstrated

that test choice was also more likely to be based on advice

from fellow colleagues, workshops and conferences rather

than evidence-based literature [19]. Ylvisaker et al. [4]

identified that evidence statements (for example guidelines)

can also impact on clinical decision-making. Time factors,

such as the available clinical time and the time required

to administer a test, have been described as impacting on

assessment choices [19–21]. Years of clinical experience has

also been highlighted as another factor that may impact on

clinical decision-making skills [4], as well as the benefits

of a mentor or experienced clinician to assist with decision-

making.

While some guidelines exist in some countries around the

world, with very little else to guide an SLP’s decision

regarding assessment selection, there has been some research

into the assessment practices of Speech Language

Pathologists working in TBI. The difficulties inherent with

this population include the heterogeneous nature of the TBI

population and the varying severity. SLPs have been reported

to use more standardized assessment practices in the acute

setting with the minimally conscious patient [22], such as the

Wessex Head Injury Matrix (WHIM [23]); and recent research

has also shown that, when a patient is in PTA (post-traumatic

amnesia), the SLP is more likely to monitor and observe any

changes than conduct a formal assessment [24].

More recently, there has been a stronger focus on

assessments for cognitive communication disorders after a

mild TBI in studies coming from the US and Australia [25].

SLPs in the US reported using the Ross Information

Processing Assessment [26], Boston Diagnostic Aphasia

Battery [27] and Boston Naming Test [28]. These results

were similar to the work by Frank and Barrineau [19], who

conducted a large scale study where severity of injury was not

defined. The initial data on assessment protocols for combat-

injured servicemen with a mild TBI highlighted selection of

assessments that were different again as part of clinical

practice. These included the Functional Assessment of Verbal

Reasoning Strategies (FAVRES) [29] and the Attention

Processing Test. Informal measures were included to examine

word finding and pragmatic deficits. Some Australian studies

have used case studies to highlight particular assessments

to use with TBI including sub-tests such as the inference/

listening comprehension sub-test from adolescent language

tests such as the Test of Language Competence [30] and The

Word Test 2 [31] vocabulary sub-test [32]. Test selection has

also been examined in the acute setting and it was found that

the Cognitive Linguistic Quick Test [33] was useful in

identifying deficits in an acute setting of 83 patients with

varying severity of TBI injury [34].

To the authors’ knowledge, there is no study which has

compared communication assessment practices in the field

of TBI between countries, although there has been some

comparison of aphasia assessment practice [35]. For aphasia,

there have been similarities between countries with the use of

the Western Aphasia Battery [15], Boston Diagnostic Aphasia

Examination [27] and Boston Naming Test [28] primarily

used by SLPs in Australia, Canada, the UK and the US. The

PALPA [36] and Mount Wilga [37] were reported to be

popular assessments in the UK and Australia compared with

Canada and the US. However, there was no difference in the

type of assessment tools used when comparing the practice

of speech pathologists working in acute settings compared to

community outpatient services. Assessment practices were

consistent across Australia in regard to the Mount Wilga High

Level Language assessment [37] predominately used by over

70% of clinicians in acute and community setting for CVA/

aphasia [20, 35, 38].

2 M. Frith et al. Brain Inj, Early Online: 1–10

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Few aphasia and TBI studies have focused on assessment

choices across settings, mainly focusing on one setting [38]

and not comparing choice of assessment tools across an

inpatient and community setting. Studies which have

reviewed assessment choice across settings have shown no

difference in the choice of tools [19, 20]. Studies have also

attempted to guide the clinician to move away from impair-

ment type tests such as aphasia assessments [39, 40] and

apply the ICF (International Classification of Functioning,

Disability and Health) model to assessment choice, with

assessments such as the FAVRES [29] and ASHA FACS [12]

for tools to assess activities and participation.

There has also been a focus on informal assessment in TBI,

primarily concentrating on discourse. Togher [41] reviewed

the theoretical approaches to discourse analysis and Coelho

[42] discussed the limitations which continue to be a barrier

to implementing this procedure. Previous research has

reported responses from clinicians who were asked about

informal assessment procedures. In literature pertaining to

both aphasia and TBI, SLPs reported using informal proced-

ures which primarily focused on observations, interviews with

the family and client and developing tools for other assess-

ments for their own use [19, 35, 38]. In the studies discussed

previously surveying SLPs about assessment practices, dis-

course analysis or discourse sampling was very rarely

reported.

Most of the research in assessment practices has focused

on the tools used and not on SLP’s perception about what they

feel are the areas of communication they assess. There is only

one paper to date which has documented this from the

perspective of SLPs [43]. This study documented SLPs

working in the US and documented that the aspects of

communication that were reported by the SLPs to be assessed

included receptive and expressive language, pragmatics,

reading, writing and cognition.

The present study was designed to identify the current

clinical assessment tools used by speech language patholo-

gists working with adults who have sustained a cognitive

communication disorder after a traumatic brain injury. The

aims of the study were to survey SLPs working in TBI and:

(1) Identify differences in the reported use of assessment

tools/protocols by SLPs in different countries.

(2) Identify whether setting of care influences the reported

use of assessment protocols/tools used by SLPs

(3) Identify whether years of experience influences the

reported use of assessment tools/protocols used by SLPs.

(4) Identify whether there was a link between all three

variables: country, setting of care and years of

experience.

Method

Participants

Speech Language Pathologists (SLPs) who reported having

specific clinical expertise in the rehabilitation of adults with

traumatic brain injury (TBI) were identified through publicly

available databases including; Speech Pathology Australia

(SPA), New Zealand Speech-Language Therapists’

Association (NZSTA), Royal College of Speech and

Language Therapists (RCSLT), Canadian Association of

Speech Language Pathologists (CASLPA) and the American

Speech-Language-Hearing Association (ASHA). These pro-

fessionals were invited to complete an online survey through

email invitation or web link using survey monkey (www.sur-

veymonkey.com). Email invitation allowed the SLPs to have

multiple opportunities to complete the survey without losing

information to which they had already responded. Three

reminders were automatically sent over a period of 8 weeks.

SLPs were also identified through Speech Pathology

Interest Groups in Brain Injury via the UK, Australia, New

Zealand, Canada and the US, as well as managers of Speech

Pathology departments throughout a number of hospitals and

community health centres. The dissemination of the survey

was modified using a general Web Link using the online

survey tool Survey Monkey (www.surveymonkey.com). This

link was not personalized to any one participant and an email

outlining the study and survey was sent to moderators of the

interest groups and managers of health services asking them

to disseminate to staff and/or colleagues. Ethics approval was

granted by the Hunter New England Human Research Ethics

Committee of Hunter New England Health reference 10/04/

21/5/10.

It was estimated that for both Australia and New Zealand

and the UK there was a greater than 50% response rate with a

lower response rate (525%) from the US/Canada group. There

was also a high rate of undeliverable emails for the US/

Canada group, which may have been an indication that the

database email addresses that were extracted were not

accurate. Overall, of those who responded, 63.4% of partici-

pants were recruited through email invitation and 36.6%

were recruited via web link. A higher number of partici-

pants were recruited through a web link in the UK

(62.3%) compared to Australia/New Zealand (13.6%) and

the US/Canada (37.2%).

Survey design

A 12 item questionnaire was developed to evaluate the

assessment practice of SLPs working in traumatic brain

injury. It formed part of a larger study, with the first seven

questions included in the analysis presented in this paper. The

seven questions asked included geographical location, clinical

setting and years of experience. A 5-point category rating

scale using fixed anchor points was used to identify SLPs’

perceptions of how often they assessed aspects of language

and communication (receptive language, expressive language,

pragmatic skills, discourse, word-finding ability, vocabulary,

high level language, problem-solving, reading decoding,

reading comprehension, written language and functional

communication). Fixed anchor points were used as they

have been recommended as more reliable when making

quantitative comparisons [44].

Descriptors were provided for each point on the rating

scale and, given the difficulties of interpreting responses

when ambiguous adverbs are used as descriptors [45], a

percentage of clinical time was provided as an additional

qualifier with the anchor points to guide the clinician in

making an accurate judgement of their assessment practices.

The quantifiers used for clinical time included; Never¼ 0%,

Infrequent 525% of clinical time, Somewhat frequent¼ 25–

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550% of clinical time, Frequently450–585% of clinical time

and the Majority of the time485% of clinical time.

SLPs were also provided with four open response text

boxes and asked to list four assessments that they use

frequently and find useful in identifying the strengths and

weaknesses of a client and assists with goal-setting and

intervention practices. These descriptors were based on

general clinical questions and principles a SLP is likely to

use when using an assessment [18].

Terminology

The generic term ‘language-based communication disorders’

was used to ensure SLPs did not respond about assessment

practices relating to dysarthria, dyspraxia and dysphagia. The

term ‘cognitive communication’ was deliberately not used in

order to prevent any response-bias by SLPs, which may return

a false positive to assessing areas of cognitive communica-

tion. The chosen terminology was utilized to promote

respondents to think broadly about what aspects of language

and communication they assess in clinical practice, with areas

relating to cognitive communication derived from responses

collected.

Analysis

Responses from Survey Monkey software were downloaded

into IBM SPSS (Statistical Package for the Social Sciences

version 21). Countries were characterized into three groups

(Australia and New Zealand; UK; US and Canada). Years of

experience were characterized into 10 years and less and

greater than 10 years and setting was characterized into

Inpatient acute/rehabilitation and Community rehabilitation.

Due to the high number of assessments reported by the

respondents, a classification system was developed based on a

Simmons-Mackie et al. [21] study which categorized assess-

ments into linguistic/cognitive, functional, subjective/qualita-

tive and vague/other. In the current study, these categories

were broadened to include aphasia assessments, cognitive

communication/high level language assessments, cognitive/

neuropsychology assessments, assessment of functional per-

formance (including literacy), informal language and cogni-

tive assessments, naming and word-finding assessments,

discourse and/or pragmatic skills assessments and other.

Assessments were categorized based on expert opinion from

five SLPs working in the area of traumatic brain injury and

aphasia. Chi-Square analysis was conducted as recommended

for categorical and ordinal data [46] to make comparison

between country, years of experience and setting of care.

Results

Responses received from 265 Speech Language Pathologists

(SLPs) are reported. Of these, 2.6% did not respond to the

rating scale question which asked how often the individual

assessed different areas language and communication; 7.6%

did not provide a list of assessments commonly used in

clinical practice in the open response text box.

Demographic information

Demographic information is represented in Table I. As shown,

the majority of SLPs reported that they worked in

metropolitan centres, while the remaining group reported

working in rural and/or remote areas. The community

rehabilitation setting predominately consisted of clinicians

working in outpatient and community rehabilitation facilities

(56.5%), private practice (17.6%) and university clinics

(14.5%).

Pearson Chi-Square analysis was conducted to confirm

whether geographical location impacted on group differences

for the key variables, experience, country and setting. There

was a significant difference between geographical location

and years of experience. SLPs with greater than 10 years

of experience were less likely to work in rural and remote

areas than SLPs with less than 10 years’ experience, �2

(1, n¼ 265)¼ 7.30, p¼ 0.007.

A three-way table with Pearson Chi-Square analysis was

conducted for employment setting and clinical experience in

each country group. Results indicated a significant relation-

ship between clinical experience and employment setting �2

(1, n¼ 263)¼ 15.31, p¼ 0.00. A relative risk ratio was

obtained to determine the likelihood of country influencing

employment setting. This is described in Table II.

In all country categories there was a higher likelihood

of experienced SLPs (greater than 10 years) working in

community rehabilitation settings compared with inpatient

settings. This was only significant for the US/Canada

category.

A logistic regression was conducted to determine the

presence of significant relationships between the three

variables of clinical experience, employment setting and

country. However, this was not significant according to the

Wald test, �2 (2, n¼ 263)¼ 2.78, p¼ 0.25.

Table I. Speech language pathologists (n¼ 265) demographicinformation.

SLPs’responses (n)

Percentage ofSLPs (%)

Geographical settingMetropolitan 210 78.9Rural & Remote 56 21.1

CountryAustralia/New Zealand 81 30.6US/Canada 113 42.6

UK 69 26Unknown 2 0.8Employment setting

Inpatient acute/rehabilitation 134 50.6Community rehabilitation 131 49.4

Years of experience510 years 121 45.7410 years 144 54.3

Table II. Relative risk for country influencing years of experience andemployment setting.

Country group Relative risk Level of significance

AUS/NZ 1.37 �2 (1, n¼ 81)¼ 1.22, p¼ 0.27UK 1.31 �2 (1, n¼ 69)¼ 1.42, p¼ 0.23US/CA 2.03 �2 (1, n¼ 113)¼ 12.84, p¼ 0.00

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Areas of communication assessed after traumaticbrain injury

SLPs reported functional communication skills (78.8%) to

be the most routinely assessed communication skill when

assessing a person after TBI. Table III highlights the

percentage of SLPs who routinely assessed each component

of communication.

Country

There were significant differences between the country where

the SLP resides and certain areas of communication. SLPs

in US/Canada (CA) reported routinely assessing problem-

solving more frequently than the UK and Australia (AUS)/

New Zealand (NZ) (�2 (8, n¼ 251)¼ 33.88, p¼ 0.00); and

frequently assessing written language (�2 (8, n¼ 243)

¼ 20.89, p¼ 0.007) and reading decoding (�2 (8, n¼ 249)

¼ 17.01, p¼ 0.030), more than SLPs in the UK and AUS/NZ.

A higher number of SLPs in the US/CA reported routinely

assessing discourse (55.7%) compared with AUS/NZ (32.0%)

and the UK (38.7%); however, this was not significant (�2

(8, n¼ 243)¼ 14.41, p¼ 0.072).

Setting of care

There were no significant differences when using a Pearson

Chi-Square between areas of communication assessed and

setting of care worldwide. In inpatient acute/rehabilitation

settings there was a higher percentage of SLPs who routinely

assessed each area of communication compared with SLPs

working in a community setting.

Years of experience

A Pearson Chi-Square revealed significant differences

between certain areas of communication assessed when

compared with years of experience of the SLP. SLPs with

more experience (410 years of experience) reported routinely

assessing more key areas of cognitive communication than

SLPs with less than 10 years of experience. These included;

pragmatic skills (�2 (4, n¼ 286)¼ 25.28, p¼ 0.00), discourse

(�2 (4, n¼ 277)¼ 25.28, p¼ 0.02), high level language (�2

(4, n¼ 287)¼ 11.99, p¼ 0.01), problem-solving (�2 (4,

n¼ 253)¼ 29.56, p¼ 0.00), word-finding (�2 (4, n¼ 288)

¼ 10.58, p¼ 0.03) and written language (�2 (4, n¼ 286)

¼ 17.17, p¼ 0.002). In addition, reading (decoding) (�2 (4,

n¼ 288)¼ 10.58, p¼ 0.003), reading comprehension (�2 (4,

n¼ 286)¼ 13.42, p¼ 0.009) and receptive language (�2 (4,

n¼ 288)¼ 10.26, p¼ 0.04) were reported as routinely

assessed more often in the more experienced clinician.

Assessment tools used in clinical practice

Overall, aphasia assessments (27.7% of SLPs) and cognitive

communication/high level language assessments (31.7% of

SLPs) were the most frequently used category of tools, as

depicted in Figure 1.

Cognitive Communication / High Level

Language Assessment

Assessment of Functional Performance (incl:

literacy)

Informal Language & Cognitive Assessments

(derived by clinicians &/or SP Dep’t)

Cognitive Neuropsychology Assessments

Naming & / or Word-Finding Assessment

Discourse & / or Pragmatic Skills

Assessment

Aphasia Assessment

Assessments Tools Used by SLPs by Category

Other

0 50 100

(9.2%)

(9.9%)

(5.6%)

(5.4%)

(6.2%)

(4.2%)

150 200 250

(27.7%)

(31.7%)

Number of Responses (n)

Total = 779

Figure 1. Distribution of assessment categories as reported by SLPs by all country groups.

Table III. Areas of communication routinely assessed by SLPs.

Area of communication Average %

Functional communication 78.8%Receptive language 70.7%Expressive language 70.3%Word-finding skills 62.9%High level language 62.6%Pragmatic skills 58.9%Problem-solving skills 57.5%Reading comprehension 48.4%Discourse 44.3%Written language 40%Reading (decoding) 34.8%Vocabulary 31.5%

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Each assessment category contained assessment tools

which were reported to be utilized more commonly than

others. The aphasia assessment category consisted of a large

number of assessments led by the Boston Diagnostic Aphasia

Examination (BDAE) [27], which was reportedly used by

23% of SLPs, closely followed by the Western Aphasia

Battery (WAB) [15] at 21.7%. Fewer assessment tools were

reported in the cognitive communication/high level language

assessment category. The Mount Wilga High Level Language

assessment (MWHLL) [37] was used by 35.2% of clinicians,

followed by the Measure of Cognitive Linguistic Ability

(MCLA) [47] on 35.2%. In the Assessment of Functional

Performance (incl: literacy) category, The Functional

Assessment of Verbal Reasoning and Executive Strategies

(FAVRES) [29] was the most popular tool at 36.4% and in the

Cognitive/Neuropsychology Assessment category, the Ross

Information Processing Assessment (RIPA) [26] was the most

popular with 27.8%. A variety of other standardized cognitive

assessments were also included in this category. The Boston

Naming Test (BNT) [28] was the most frequently used

assessment in the Naming and/or Word Finding Assessment

category, with 66.7% of SLPs reporting their use of that

particular tool. The La Trobe Communication Questionnaire

(LCQ) [48] was the most popular tool in the Discourse/

Pragmatic Skills Assessment category, with 35.4% reporting

use of the assessment, followed by The Awareness of Social

Inference Test (TASIT) [49], with less than 20%. Various

outcome measures and paediatric language assessments

comprised the other category.

Country

A Pearson chi-square was conducted to determine if there was

a difference in assessment tools used between countries.

Results indicated a significant difference between countries

�2 (14, n¼ 779)¼ 97.31, p¼ 0.00. Table IV shows the

comparison of assessment tools by SLPs from each country.

SLPs in the US/CA reported a lower use of Cognitive

Communication/High Level Language Assessment tools

while SLPs in AUS/NZ reported significantly higher use.

In contrast, SLPs in the US/CA reported higher use of

Cognitive/Neuropsychology Assessment tools when com-

pared with SLPs in the UK and AUS/NZ. However, SLPs

in AUS/NZ reported higher use of informal language and

cognitive assessments and slightly higher use of naming/word

finding assessments and discourse and pragmatic skills

assessments. SLPs in the US/CA reported lower use of

assessment tools for discourse and pragmatic skills.

Particular assessment tools were also reported as more

popular by country. In AUS/NZ and the UK there was less

variability in assessment tools reported compared with the US

and Canada, which mostly consisted of cognitive/neuropsych-

ology assessments. AUS/NZ and the UK also had very similar

popularity with assessment tools. In AUS/NZ the most

reported assessment tools used included the MWHLL [37]

with 77.2%, MCLA [47] with 45.6%, informal assessment

practices with 32.9% and Psycholinguistic Assessment of

Language Processing in Adult Acquired Aphasia (PALPA)

[36] with 30.4%.

In the UK the most reported assessment tool was the

MCLA [47] at 55.4%, followed by CAT [50] at 46%,

MWHLL [37] at 43% and the PALPA [36] at 40%. In the

US/CA, the WAB [15] and BDAE [27] were most popular at

30.5% and the Scales of Cognitive Ability for Traumatic

Brain Injury (SCATBI) [51] at 29.5%, CLQT [33] and

informal assessment practices both at 24% and the RIPA [26]

on 23% were the most frequently used assessments. See Table

V for the popular assessment tools in each country.

Setting of care

A Pearson chi-square was conducted to determine if there was

a difference in assessments tools used within inpatient and

community settings. Results indicated a significant difference

between setting of care (�2 (14, n¼ 779)¼ 18.60, p¼ 0.01).

Table VI shows the comparison of assessment tools by setting.

Discourse was the only assessment category which was

significantly different amongst settings with discourse and

pragmatic skills assessment more likely to be completed in a

community setting. Most assessment categories were report-

edly used more often in an inpatient setting, except for

discourse (which was significant), cognitive assessments,

word-finding assessments and other assessments.

Years of experience

There were no significant differences with reported level

experience and assessment tools used by SLPs �2 (7,

n¼ 779)¼ 4.17, p¼ 0.760. There was also very little variance

Table IV. Comparison of assessment tools by country.

Country (% of use)

Assessment tool Average % AUS/NZ UK US/CA

Aphasia Assessment 27.7 25.9 32.7 25.9Cognitive Communication/High Level Language 31.7 39.9* (+) 33.2 23.6* (�)Cognitive/Neuropsychology Assessments 9.2 0.8* (�) 6.6 18.4* (+)Assessment of Functional Performance (incl: Literacy) 9.9 8.0 6.6 13.8* (+)Informal Language/Cognitive Assessment 5.6 9.5* (+) 2.4* (�) 4.6Naming and/or Word Finding Assessment 5.4 3.0* (�) 6.2 6.9Discourse and/or Pragmatic Skills Assessment 6.2 9.1* (+) 6.2 3.6* (�)Other Assessment 4.2 3.8 6.2 3.3

An adjusted standardized residuals test was carried out to determine if there were differences amongst countries on particular assessment tools.Residuals which exceeded ± 2 are presented, with a + indicating significantly higher use of assessment tool compared to average of all SLPs.A � indicates significantly less use of that assessment tool compared to average of SLPs who participated in survey. *indicates p50.001.

6 M. Frith et al. Brain Inj, Early Online: 1–10

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between assessments used between clinicians with greater

experience and, while it was not significant, more experi-

enced clinicians (410 years) were more likely to complete a

cognitive/neuropsychology and discourse/pragmatic skills

assessment and less likely to conduct an informal language/

cognitive assessment with a client after a traumatic brain

injury.

Discussion

This study’s primary objective was to examine the current

assessment practices of SLPs working with adults with

acquired cognitive communication impairments following a

TBI. It aimed to identify potential differences in the use of

assessment tools and protocols by SLPs across prominent

English speaking countries worldwide and whether setting of

care and years of clinical experience influenced these choices.

The results of the worldwide survey of clinicians in this field

informed each of these areas and highlighted a number of

clinical and research implications.

Overall, when assessing adults communication skills after

a TBI, SLPs reported assessing functional communication

skills the most frequently in clinical practice followed by

receptive and expressive language skills. Areas of communi-

cation considered to be sensitive to TBI [52, 53], such as

pragmatic skills, word finding skills, higher level language

abilities, discourse, literacy and problem-solving skills, were

not routinely assessed by SLPs, regardless of country, setting

or years of experience. In particular, discourse/pragmatic

skills assessment tools were used by less than 10% of the

SLPs surveyed and findings showed that discourse assess-

ments currently used included checklists such as the LCQ [48]

or the social communication assessment TASIT [52]. These

assessments have already had research conducted to evaluate

their validity and reliability which have been positive [52, 54].

These results about the assessment of discourse may contrib-

ute to a possible trend in the literature, suggesting that

perceived time taken and ease of transcription, training, the

decision process regarding the type of assessment/tool and

translating the findings into clinical practice may still be

possible deterrents for a SLP to implement discourse analysis

into clinical practice [42].

Interestingly, while Functional Communication was rated

as the most routinely assessed area of communication,

impairment-based assessments designed for aphasia and

high level language were noted to be the most prevalently

used by SLPs internationally. To date, only one assessment in

this category has been recommended for use in this popula-

tion of adults with TBI [9]: the WAB [15]. Further research

needs to evaluate why other assessments in the category of

aphasia assessments that were revealed by the survey, such as

the PALPA [36], CAT [50] and BDAE [27], are used in

clinical practice if impairment-based aphasia tools are

generally not reported in the literature to be sensitive to TBI

nor considered appropriate to the targeted function in

everyday life [39]. Most of the assessments commonly used

in studies examining cognitive communication impairments

in TBI were not identified as preferred assessment tools in

clinical practice in this study, except for the SCATBI [51],

which again has not consistently proved sensitive to milder

deficits after TBI [32, 55].

Differences were also noted between the countries repre-

sented in the survey in regards to the assessment of specific

areas of communication as well as the assessment tools used.

In the US and Canada (US/CA), SLPs more frequently

assessed areas of communication such as problem-solving,

written language and reading compared to their colleagues in

Australia/New Zealand (AUS/NZ) and the UK. As high-

lighted by past research [43], SLPs in the US are using a high

number of cognitive assessments compared to linguistic

assessments and this may be a reflection of the guidelines

distributed in the US and Canada [6–8], which highlights

cognition as an area of assessment for the SLP. Studies which

have reviewed the role of the SLP in regards to assessment of

cognition have demonstrated the overlapping role between

SLPs and Neuropsychologists [56]. A large majority of

Neuropsychologists saw the role of the SLPs was to assess

cognition as part of an assessment of communication, but

there was very little collaboration with pre-assessment

planning which had implications for integrity of psychomet-

ric assessments and the reporting of results as each discip-

line had its own interpretation and perspective view [56].

Table VI. Comparisons of assessment tools by setting.

Average(%)

Inpatient(%)

Community(%)

Aphasia Assessment 27.7 29.8 25.6Cognitive Communication/

High Level Language31.7 33.9 29.5

Cognitive/NeuropsychologyAssessments

9.2 7.9 10.6

Assessment of FunctionalPerformance (incl: Literacy)

9.9 10.5 9.3

Informal Language/CognitiveAssessments

5.6 6.4 4.9

Naming and/or Word FindingAssessments

5.4 4.8 5.9

Discourse and/or Pragmatic SkillsAssessments

6.2 3.1* (�) 9.3* (+)

Other 4.2 3.6 4.9

An adjusted standardized residuals test was carried out to determine ifthere were differences setting on particular assessment tools. Residualswhich exceeded ± 2 are presented with a +, indicating significantlyhigher use of assessment tool compared to average of all SLPs. A �indicates significantly less use of that assessment tool compared toaverage of SLPs who participated in survey. *indicates p¼ 0.01.

Table V. Popular assessment tools by country.

OverallAustralia/

New Zealand UK US/Canada

1 MWHLL MWHLL MCLA WAB/BDAE2 MCLA MCLA CAT SCATBI3 BDAE PALPA MWHLL CLQT/Informal4 WAB Informal PALPA RIPA

MWHLL, Mt Wilga High Level Language [37]; MCLA, Measure ofCognitive Linguistic Ability [47]; BDAE, Boston Diagnostic AphasiaExamination [27]; WAB, Western Aphasia Battery [15]; PALPA,Psycholinguistic Assessment of Language Processing in AdultAcquired Aphasia [36]; CAT, Comprehensive Aphasia Test [50];CLQT, Cognitive Linguistic Quick Test [33]; Informal, Informal testsmade up by the clinician; SCATBI, Scales of Cognitive Ability forTraumatic Brain Injury [51]; RIPA, Ross Information ProcessingAssessment [26].

DOI: 10.3109/02699052.2014.947619 Cognitive communication following TBI in adults 7

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This has implications for clinical practice about the clinical

decision-making rationale behind choosing cognitive-based

assessments over linguistic-based assessments.

Conversely, the results of the present study demonstrated

that cognitive communication and high level language

assessments (CC/HLL) were used significantly less by SLPs

in the US/CA compared to SLPs in AUS/NZ. The most

widely used CC/HL assessments in AUS/NZ and the UK

were the MWHLL [37] and the CLAMCLA [47]. The use of

the MWHLL has been documented as a preferred assessment

in Australia in adults with aphasia [35, 38], a finding which

was also evident in the current study in demonstrating

its popularity amongst clinicians for use with adult TBI

patients as well. This is an interesting finding considering

there is no known empirical research or normative data

supporting its use in clinical practice to date. The MWHLL

assessment is available online free (for example

www.Libguides.city.ac.uk) and may influence SLP choice

based on availability rather than on psychometric robustness.

However, further research is warranted to establish appropri-

ateness for individual assessments with this population in

order to guide the SLP in making the best tool selections to

assess cognitive communication abilities in adults after TBI.

It also may serve to further highlight previous research

indicating that SLPs do not place great emphasis on statistical

properties of an assessment when choosing an assessment

tool [19].

Although discourse/pragmatic assessment tools repre-

sented a smaller proportion of assessment tools reported to

be used by SLPs surveyed in this study, this category was

noted to be more prevalent in AUS/NZ settings. This may

reflect that the stated assessments of choice were more

commonly developed locally, with the potential for AUS/NZ

based SLPs to have had more exposure to these tools via

workshops or conferences; reported to be an effective method

of promoting assessment choice [19]. Similarly, use of the

FAVRES [29] in the assessment of functional performance

category was noted to be more popular in the US/CA from

where it also originated. These findings suggest that the

location where the assessment is developed may influence

SLPs local to that area in their choice of assessment tool.

Naming assessments were used significantly less in AUS/

NZ, as were cognitive assessments which may reflect role

delineation between Neuropsychologists and SLPs in those

countries. The BNT which was the most popular tool in the

naming group has also been reported as a tool used by

Neuropsychologists when examining their clinical assessment

practices [57].

Use of informal language/cognitive measures were not

considered as a preferred method of assessment by SLPs in

the UK and US/CA, with less than 3% and 5% using them,

respectively, whereas closer to 10% reported use of these

assessments in the AUS/NZ group. Of those used, tools

selected from this category focused mainly on observations of

non-specific functional activities or assessments developed by

the clinician. Observation is one form of informal assessment

that has been previously reported to be a preferred choice for

both TBI and aphasia patients [19, 21, 38]. However, further

research is required about the validity of this category of

assessment given there is no normative data and individuality

of communication styles and context-specific nature of

communication in different settings [41].

The survey conducted as part of the present investigation

highlighted that overall SLPs do not report assessing a

particular area of communication more frequently depending

on clinical setting; whether it was an inpatient or community

setting. The majority of assessments were used equally

across inpatient and community setting, similar to findings in

previous research examining clinical assessment practices in

both TBI and aphasia populations [19, 35]. However, at a

category level, discourse and pragmatic skill assessment tools

were noted to be significantly more likely to be used in a

community setting. As discourse and social skills are con-

sidered by clinicians to play a significant role in re-establishing

peer relationships and re-integrating back to work [58], it is

possible that SLPs specifically target social communication in

their assessment and rehabilitation practices in order to support

re-integration of their patients back into the community.

Methodological issues such as practice effects on repeated

measures needs to be highlighted given the lack of change in

assessment tools between inpatient and community settings.

The possible use of re-testing using the same assessment

within short time frames as the person with a TBI follows

their rehabilitation from inpatient to community and possibly

a number of different clinicians. Given previous research

highlighting that SLPs have focused less on statistical

properties [19], further investigation is warranted in deter-

mining how often assessments are re-administered in clinical

practice and whether this impacts not only on the validity and

reliability, but also regarding appropriateness for goal setting,

intervention planning and as an outcome measure.

Those areas of communication demonstrated to be more

specifically impacted or sensitive to TBI [53], such as

pragmatic skills, discourse word finding ability and literacy,

were more likely to be more frequently assessed by

experienced clinicians. However, the tools selected in the

assessment of these areas of communication were not signifi-

cantly different in regard to years of experience. Previous

research has highlighted that clinicians did not feel adequately

trained at an undergraduate level and that experience of TBI

is learnt through exposure, mentoring from experienced

staff and workshops [19]. Additionally, findings of the present

study suggest that less experienced staff in AUS/NZ are

working in regional and rural areas, often times employed as a

sole or generalist clinician, where they may not have access

to the appropriate assessment tools or support in deciding on

which appropriate tools to use. Such reports of inconsistent

use of assessments targeting areas of communication known

to be most commonly impacted by a TBI [3, 52, 59], regardless

of level of experience, further supports the importance of

further education and training. The development of prescrip-

tive guidelines worldwide may also prove useful, suggesting

what areas of communication should be assessed and the tools

that could be used as part of an assessment protocol to address

not only impairment but also tools that reflect functional

activities and participation in the community [40]. Training

programmes linking rural clinicians with metropolitan clin-

icians are also recommend and have been shown to be an

effective method in mentoring and supporting allied health

professionals in these settings [60].

8 M. Frith et al. Brain Inj, Early Online: 1–10

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A potential limitation of this study is the potential sample

bias, in that SLP survey participants were recruited based on

their own perception of identification using previous experi-

ence with populations/patients with TBI. SLPs were asked if

they had specialist experience working with adults with TBI.

The extent of specific TBI experience or the frequency they

may assess a client with TBI was not explicitly asked. It is,

therefore, possible that SLPs with minimal or extremely

limited experience in TBI may have participated in the survey,

although this was minimized by recruiting through special

interest groups in brain injury throughout each country. An

additional limitation is that there are also potential weaknesses

in using Likert scales due to their subjective nature of evalu-

ation and evidence that suggests that people from different

cultures and countries may answer a question on a Likert scale

more or less positively [61]. To manage this possible

weakness, the use of Likert scales was supplemented with

open-ended questions, which offered participants the oppor-

tunity to provide detail about their current clinical practice.

In addition, categorizing assessments into groups is not

always straight forward as an assessment can have multiple

sub-tests which may overlap into other categories or there

might be different perspectives of where an assessment might

be best categorized and this has been highlighted in previous

research which has attempted to map assessments to the ICF

model [40]. Nonetheless, this was addressed by obtaining

agreement from a panel of five experienced researchers in the

field of TBI on the assignment of tests to categories. Further

study is warranted to ascertain whether an assessment that is

used, is used in its entirety or parts of the assessment are used.

In conclusion, this study is the first to document

international assessment practices of SLPs working with

adults who have a cognitive communication disorder after a

TBI. Similarities between countries highlights that traditional

impairment-based aphasia tools continue to be favoured, with

less focus on specific functional assessment tools, yet

reported routinely assessing functional communication

skills. Guidelines regarding the role of SLPs’ assessment of

cognitive communication disorders were noted to have

influenced change in assessment practices in some countries,

such as the US, with cognitive assessment tools forming an

important part of a clinical assessment protocol. Countries

without guidelines such as Australia, New Zealand and the

UK focus on assessment protocols from the field of aphasia

and use aphasia and or cognitive communication/high level

language assessments. The use of discourse analysis in clinical

practice is still not used readily as part of an assessment

protocol. The study supports the need for clearer recommen-

dations and guidelines about assessment protocols for assess-

ment of cognitive communication disorders after a TBI.

Declaration of interest

The authors report no conflicts of interest. The authors alone

are responsible for the content and writing of the paper.

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